Basic Information
| Provider Information | |||||||||
| NPI: | 1679864797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERTON | ||||||||
| FirstName: | RUBY | ||||||||
| MiddleName: | FAITH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 PASEO DE LAURA UNIT 61 | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149168870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6250 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920091603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604762900 | ||||||||
| FaxNumber: | 7609404007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2011 | ||||||||
| LastUpdateDate: | 04/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5494 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5494 | 01 | CA | PHYSICAL THERAPY BOARD OF CALIFORNIA | OTHER |